Pre-Procedure History & Physical (Pediatric Endoscopy)

This note represents: [Full pre-procedure H&P / Interval H&P update] (If interval update, reference date of original H&P and document what has or has not changed since that evaluation.)

Date/Time of evaluation: [Date and time]

Patient name: [Name]

Date of birth: [DOB]

MRN: [Medical record number]

Weight: [Weight in kg] Height: [Height] (Include if available.)

Scheduled procedure date/time: [Date and time]

Planned procedure(s): [EGD / Colonoscopy / EGD and Colonoscopy / Flexible sigmoidoscopy / Other]

Proceduralist: [Name, credentials]

Sedation/Anesthesia model: [Anesthesia service / Endoscopist-directed moderate sedation / Endoscopist-directed deep sedation / Other]

Legal guardian present and available: [In person and available / Reachable by phone / Not present / Unknown] (Document as unknown if not verified; do not infer.)

Interpreter used: [None / Yes—language and modality / Unknown]

Source(s) of history: [Patient / Parent or guardian / Chart review / Other]

Planned Procedure & Indication

• Clinical indication and question: [Primary indication and specific clinical question to be answered]
• Planned extent: [Upper only / Lower only / Upper and lower]; Terminal ileum intubation: [Yes / No / If feasible]
• Anticipated interventions: [Biopsies / Polypectomy / Dilation / Hemostasis / Foreign body removal / None planned / Other]
• Differential affecting planning or risk: [Brief list if applicable] (Include only if it materially affects procedural strategy or risk; otherwise omit.)

Focused GI History

[Narrative of symptom onset, duration, severity and trajectory, triggers, and response to prior therapies. Address relevant red flags: GI bleeding, dysphagia or food impaction, bilious or persistent emesis, chronic diarrhea, nocturnal symptoms, weight loss, fevers, growth faltering. Use brief patient quotes for subjective symptoms when helpful for clarity.] (If history is limited by developmental status, language barrier, or time constraints, document why and what sources were used.)

[Nutrition and hydration status. Clinically meaningful results from prior testing including labs, stool studies, imaging, and prior endoscopy with pathology. If outside records were reviewed, state this and summarize only decision-relevant elements.]

Sedation & Anesthesia Risk History

• Prior anesthesia/sedation: [Tolerated well / Complications: difficult intubation, laryngospasm, bronchospasm, aspiration, severe PONV, malignant hyperthermia concern, prolonged emergence / Unknown] (If unknown, note whether verification was attempted.)
• Airway/OSA risk factors: [Snoring / OSA diagnosis / Tonsillar hypertrophy / Craniofacial anomalies / Limited neck mobility / Neuromuscular disease / None]
• Cardiopulmonary history: [Congenital heart disease / Pulmonary hypertension / Chronic lung disease / Baseline oxygen requirement / None]
• Recent/current illness: [URI symptoms / Fever / Wheeze / None] (Include onset and course if present.)
• Aspiration risk features: [Severe reflux / Delayed gastric emptying / Obstruction symptoms / Swallowing dysfunction / None]
• Special population considerations: [Age under 1 year / Medically complex / Obesity / Neuromuscular weakness / Developmental delay / None]
• Family history of anesthesia complications: [None / Malignant hyperthermia / Pseudocholinesterase deficiency / Other / Unknown]

Pertinent Medical & Surgical History

• Active conditions relevant to procedure/sedation: [Problem list prioritizing coagulopathy, thrombocytopenia, chronic liver disease, portal hypertension, immunocompromise, connective tissue disease, severe IBD activity]
• Devices: [VP shunt / Tracheostomy / Gastrostomy / Central line / Other / None]
• Prior surgeries: [GI surgery with altered anatomy / Airway surgery / Cardiac surgery / Other relevant procedures] (Omit remote or unrelated surgeries.)

Medications & Allergies

• Current medications: [Name, dose, route, frequency for each]
• High-risk agents: [Chronic sedatives / Anticonvulsants / Steroids / Anticoagulants or antiplatelets / Insulin or diabetes medications / Biologics or immunosuppressants] (List separately for visibility.)
• Critical medication last-dose timing: [Obtained with times / Unavailable / Partial] (State explicitly if unavailable; do not guess.)
• Allergies: [Agent and reaction type for each; note latex allergy if present] or [No known drug allergies—verified] (Confirm NKDA reflects verified history rather than default entry.)

Pre-Procedure Readiness

• NPO status: Solids [time]; Formula [time or N/A]; Breast milk [time or N/A]; Clear liquids [time]
• Colonoscopy prep: [Completed / Incomplete / N/A]; Last BM character: [Clear liquid / Brown liquid / Particulate / Formed / Unknown] (Include only for lower endoscopy.)
• Intercurrent changes since last evaluation: [New symptoms / ED visits / New medications / New allergies / Acute illness / None]
• Relevant labs/imaging reviewed: [CBC / Coagulation studies / Other] (Include only items affecting procedural safety or planning.)
• Baseline support needs: [Home oxygen / Ventilator dependence / Feeding tube / Special positioning / None]
• Information gaps: [What could not be obtained and how addressed] (Document only if key readiness information is unavailable.)

Physical Exam

• Vital signs: [HR, BP, RR, SpO2, Temp] (Note if febrile.)
• General: [Appearance, distress level, hydration status]
• Airway: [Mouth opening, dentition, loose teeth, visible anatomy, neck mobility, dental hardware]
• Cardiovascular: [Rate, rhythm, murmurs]
• Respiratory: [Work of breathing, wheeze or crackles, baseline oxygen needs]
• Abdomen: [Distension, tenderness, guarding, masses, ostomies, tubes]
• Neurologic: [Mental status, baseline tone] (Include if relevant to sedation risk.)
• Lines/tubes/devices: [Central line / G-tube / Tracheostomy / Other / None]
• Deferred elements: [Element and reason] (Document reason if any exam element could not be assessed; do not leave blank.)

Assessment

[Indication summary linking symptoms and data to why endoscopy is indicated now. State why timing is appropriate and expected diagnostic or therapeutic yield.]

• Sedation/anesthesia risk: [Age under 1 / Congenital heart disease / Pulmonary hypertension / Difficult airway features / Recent URI / None identified / Other]
• Bleeding risk: [Coagulopathy / Thrombocytopenia / Portal hypertension / Active severe colitis / Planned polypectomy / Anticoagulant use / None identified]
• Perforation risk: [Known or suspected stricture / Severe IBD flare / Connective tissue disease / Altered anatomy / None identified]
• Infection risk: [Immunocompromised / Prophylaxis indicated / Indwelling devices at risk / None identified]

ASA Physical Status: [I / II / III / IV / Not assigned by this service—anesthesia will determine] (If not assigning, note relevant factors affecting classification.)

Plan

• Clearance decision: [Cleared to proceed / Deferred—rationale]
• Procedure plan: [Extent, terminal ileum intubation intent, anticipated interventions]
• Anesthesia coordination: [Sedation model confirmed; risk flags communicated; special equipment or expertise requested] (Document closed-loop handoff.)
• Day-of medication instructions: [Medications to take, medications to hold] (Specifically address antiseizure medications, insulin, and steroids per institutional guidance.)
• Antibiotic prophylaxis: [Not indicated / Indicated—regimen and rationale]
• Family counseling: [NPO reinforcement, instruction to report new URI or fever, post-procedure expectations]
• Consent: [Obtained and documented in: location] or [To be obtained prior to procedure]
• Questions addressed: [Questions answered; family and patient in agreement with plan]